687370

research-article2017
FASXXX10.1177/1938640016687370Foot & Ankle SpecialistFoot & Ankle Specialist

vol. XX / no. X Foot & Ankle Specialist 1

〈 Review 〉
Literature Review of
Idiopathic Toe Walking David Pomarino, Juliana Ramírez Llamas,
MSc, Stephan Martin, MD,

Etiology, Prevalence,
and Andrea Pomarino, MD

Classification, and Treatment

Abstract: Purpose: The main
objective of this review is to gather the
information available about idiopathic
toe walking (ITW), its prevalence and
classification, and possible therapeutic
approaches. In addition, this review
aims to clarify the differences between
idiopathic toe walkers and tiptoe
walkers with underlying neurological
Keywords: review; idiopathic toe
walking; tiptoe walking pattern;
classification; prevalence; etiology;
treatment; evaluation
Introduction
Idiopathic toe walking (ITW) was first
described as a congenitally short
their feet flat on the ground when
concentrating on their gait or on
request.5-7
The dorsiflexion range of motion of
some children is limited (0°’5°),1,4 whereas
others have a decreased or normal
dorsiflexion between 5° and 20°,8,9 and
Achilles tendon contractures may or may
not be present.9-11 The gait pattern looks

“
or muscle deficiency as primary Achilles tendon1 and
conditions. Understanding its causes currently is defined as a
and learning to make a differential pathological gait pattern A positive family predisposition has
diagnosis will help determine the on the tiptoes with no
adequate therapeutic approach. neurological or been reported in 30% to 42% of the
Methods: This is a review of different 2,3
orthopedic cause. It is
articles and case studies from 1967 to also described as the children with habitual toe walking, but
2016. The information was gathered to
update and unify all the information
abnormal persistence of for about 60% of these children, the
primarily physiological
about ITW that has been published.
Conclusion: The literature offers
toe walking after 2 cause is unknown.”
years of age.4 An
limited research regarding the possible absence or limitation of
etiology, prevalence, classification, heel strike during the
and evaluation of ITW. This review initial contact of the gait cycle is well coordinated and symmetric, and the
puts together all the information 2
observed ; weight bearing occurs on the children can run at normal speed.4
regarding the etiology, prevalence, front of the foot. Usually, the toe-toe
classifications, evaluation, and gait pattern is characterized by an onset Etiology
treatment of ITW.
from the beginning of walking; A congenital short Achilles tendon was
Levels of Evidence: IV nevertheless, toe walkers can support described by Hall et al12 in 1967. The

DOI: 10.1177/1938640016687370. From Praxis Pomarino, Hamburg, HH, Germany (DP, JRL, AP), and Diakiniekrankenhaus Annastift GmbH, Hannover, Germany (SM).
Address correspondence to: Juliana Ramírez Llamas, MSc, Praxis Pomarino, Rahlstedter Bahnhofstrasse 9, 22143 Hamburg, Germany; e-mail: julir83_ramirez@yahoo.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2017 The Author(s)
2 Foot & Ankle Specialist
Table 1.
Classification of Idiopathic Toe Walking Based on Gait Analysis (Alvarez et al).20
Toe Walking
Severity Group Presence of Ankle Rocker
Type 1
Type 2 Yes or no
Type 3
subjects of the study were described as
children who had a bilateral contracture
of the calf muscles but were able to bear
weight on their heels on request. These
children were most comfortable walking
on their toes. There were 2 families that
reported more than one affected child,
but no family predisposition was
described in the study. The only
deformity reported was in the equinus of
both ankles, from 30° to 60°, with neither
muscle weakness nor decrease of
sensation.
A positive family predisposition has
been reported in 30% to 42% of the
children with habitual toe walking,9,13-16
but for about 60% of these children, the
cause is unknown. So even though
family predisposition plays an important
role, currently, the causes of this gait
anomaly are still not understood.
It has been suggested that a sensory
processing dysfunction can cause toe
walking.7 The explanation for this is that
the integration of the vestibular,
proprioceptive, and tactile systems does
not provide adequate information to the
brain. Feedback that normally occurs
during and after every activity does not
function properly. In this case, a sensory
processing dysfunction should be
diagnosed. However, this theory is still
under investigation and further studies
are suggested.4,7,17,18
All the definitions found in the
literature rule out orthopedic or
neurological reasons for toe walking. In
many studies of toe walkers, the children
are described as healthy individuals who
walk on tiptoes. Their strength, reflexes,
Primary Criteria and Definitions
Presence of Early Third Rocker
Yes No
Yes or no
No Yes
and sensation are normal. In addition,
the pattern is described as bilateral, and
the children are able to place the heel
on the ground when asked to do so.
They are able to modify their walking
pattern when concentrating on it.
Classifications
Idiopathic toe walkers can be classified
into 2 types. One is the Alvarez
classification, which is based on the
kinematic of the ankle while walking,
and the second is the Pomarino
classification, which is based on clinical
features found in toe walkers.
Alvarez’s Classification
Alvarez’s classification determines the
severity of toe walking according to the
presence of ankle rockers According to
Perry,18 the ankle kinetic is divided into 3
rockers. On the first rocker, the heel
meets the ground and heel strike takes
place followed by an ankle plantiflexion;
during this instant, there is an eccentric
contraction of the anterior tibial muscle.
At the second rocker, there is an
eccentric contraction of the
gastrocnemius with some dorsiflexion; at
the third rocker, the pushoff action takes
place, the ankle plantiflexes, and there is
concentric contraction of the
gastrocnemius and soleus muscles. In toe
walkers, the rockers are modified. There
is an absence of the first rocker, so the
foot strike occurs on the sole or on the
forefoot instead of the heel; the second
rocker is inverted, and during the swing
phase, disruptions with increased
Mon XXXX
Predominant First Ankle Moment
No
No
Yes
plantiflexion take place.19 Therefore, the
Alvarez classification categorizes 3
severity types according to the presence
of the rockers (Table 1).
Westberry et al19 studied the kinematic
and kinetic differences of toe walkers,
and they identified differences in the
knee and the ankle compared with mild
cerebral palsy. They also identified that
about 70% of toe walkers are able to
adjust or normalize either the stand or
the swing phase, and just about 17% of
the children were able to normalize both
variables (stand and swing phase).
Pomarino’s Classification
According to Pomarino, children who
tiptoe walk exhibit a range of different
characteristics; therefore, this gait
anomaly may be a result of different
conditions. Pomarino et al21 classified the
toe walkers according to the physical
features found during clinical
examination. According to this
classification, idiopathic toe walkers are
divided into 3 types:
Type I: This group of toe walkers is
born with a short triceps surae
muscle, which produces the tiptoe
walking pattern. They are recognized
by having a heart shaped calf (Figure
1) deep wrinkles (Figure 2) over the
Achilles tendon area, and a fat
deposit on the forefoot (Figure 3)
under the second and third metatarsal
bones. Other common features are a
pointy heel, a pes cavus, and a short
adductor magnus muscle.
vol. XX / no. X
Figure 1.
Heart-shaped calf: the
gastrocnemius muscle’s belly is
heart shaped. The 2 bellies show up
on the sides.
Figure 2.
Wrinkles on the Achilles tendon
area: there are deep wrinkles on
the Achilles tendon area; usually,
they are observed also during the
dorsiflexion motion.
Type II: This group has a positive
family predisposition, they present
with a “V” sign over the Achilles
tendon area (Figure 4), and the
gastrocnemius muscle is
hypertrophied (Figure 5).
Type III: This group usually can
support the heel on the ground while
Figure 3.
Forefoot padding: this padding
formation located under the second
and third metatarsal bones.
Figure 4.
V-shape on the Achilles tendon: a
V-shaped on the Achilles tendon
is observed when the foot is
dorsiflexed.
walking. Frequently between 4 and 5
years of age, the tiptoe gait pattern
resolves spontaneously. The pattern
may continue to appear in some
situations such as fear, anxiety,
tiredness, or stress.
Differential Diagnoses
There are 2 other groups of children
who walk on the forefoot who are often
diagnosed as idiopathic toe walkers.
Genetic Sensorial Neuropathy Type
I.  These children tend to be
misdiagnosed as idiopathic toe walkers;
however, the tiptoe walking pattern is
Foot & Ankle Specialist 3
Figure 5.
Hypertrophy of the medial
gastrocnemius: the medial head
of the gastrocnemius muscle is
hypertrophied.
Figure 6.
Claw hand and foot.
caused by a neuropathy. These children
often present with a claw hand (Figure
6) and foot deformity and a hypotrophy
of the gastrocnemius muscles (Figure 7).
So far, there has been just 1 case study
that describes this neuropathy.22
Mc Ardle Disease.  Many children with Mc
Ardle disease are diagnosed as idiopathic
toe walkers. The general features observed
in these children are hypotrophy of the
girdle muscles (Figure 8) a wider forefoot
(Figure 9), and a more proximal belly of
the gastrocnemius muscle.10 However,
there are just 2 case studies that report
children with Mc Ardle disease who
walked on their toes.
Even though these last 2 groups of
children walk on their toes, they do not
belong to the group of children with
idiopathic toe walking because the first
one is caused by a neurological
condition and the second by a muscular
condition. However, there is still more to
4 Foot & Ankle Specialist
Figure 7.
Calf hypotony: the gastrocnemius
belly is much thinner and the calf
looks slimmer.
Figure 8.
Girdle muscles hypotrophy: The
shoulder muscles are hypotrophied,
and during shoulder abduction there
is a hypotrophy of the lateral portion
of triceps brachii or the long head of
the biceps.
Figure 9.
Wider forefoot.
Figure 10.
Gastrocnemius muscle with
proximal orientation: the
gastrocnemius muscle has a
proximal orientation and seems to
be hypertrophied.
investigate in this area, and the reasons
why these children exhibit the tiptoe
walking pattern are still unknown.
Pomarino and colleagues were not
alone in acknowledging different
characteristics among the toe walkers. In
a study of 28 children, Furrer and
Deonna23 identified different toe walker
groups: (1) children who toe walk as a
result of a neurological impairment; (2)
habitual toe walkers with neither motor
delay nor limited dorsiflexion; (3) children
with a congenital short Achilles tendon
and limited ankle dorsiflexion, where the
“congenital short Achilles tendon” that
causes the limitation may evolve later; and
(4) a last group with mixed or unclassified
characteristics. In addition, a positive
family predisposition is discussed. There
are also other authors who have observed
and identified different characteristics
among toe walkers.
Evaluation
The severity of the tiptoe walking
pattern can be measured by any of 5 tests.
These are reported in Pomarino et al.24
Mon XXXX
Performance of Spin Test
The patient is requested to spin around
fast in one spot for a maximum of 10
spins. The number of spins in which the
patient gets on the toes is recorded. The
test is positive when the tiptoe walking
pattern appears. The earlier the tiptoe
walking appears, the more affected the
patient is by toe walking.
Performance of Walking
After Spin Test
Immediately after the spinning test, the
patient is requested to walk 10 steps in a
straight line. The step at which the toe
walking appears is recorded. The earlier
the tiptoe walking reappears, the more
affected the patient is by toe walking.
These last 2 tests were designed to
evaluate the equilibrium and to provoke
the tiptoe walking pattern.
Performance of the
Heel Walking Test
The patient is requested to heel walk.
Compensations such as flexion and/or
external rotation of the hip or a decrease
in ankle dorsiflexion are allowed. The
test is considered positive for toe walking
if the patient is unable to heel walk or
heel walks exhibiting trunk, knee, and
ankle compensations. This test was
designed to measure the tibialis anterior
strength while walking. The observation
of compensatory movements that help
achieve the heel flexion is important.
Range of Motion for the Ankle
Joint in Dorsiflexion
Measurement of ankle dorsiflexion with
flexed knee and extended knee has been
used in different studies. The greater the
ankle limitation, the more affected the
patient.
Angle Degree of the
Lumbar Lordosis
The lumbar lordosis is measured with a
goniometer. It is placed at the greatest
convexity of the lumbar spine. The patient
is more affected if the lordosis is more
vol. XX / no. X
pronounced. This test was chosen because
earlier studies showed that toe walkers
exhibit an increased lumbar lordosis angle.
Therapeutic Approaches
A large variety of treatments can be
recommended for idiopathic toe walkers.
The options vary from conservative to
surgical approaches. However, results
vary in terms of their long-term
effectiveness.
Physical Therapy
Physical therapy is one of the most
common treatment options for children
with idiopathic toe walking. The aim is
to stretch the gastrocnemius muscle
using exercises and to increase active
dorsiflexion.14,25 However, the literature
about technique, methods used, and
treatment results is limited.
Casting
There are multiple studies related to the
use of casting. The aim of the casting is to
elongate the noncontractile structures, and
the duration is about 2 to 10 weeks. There
are a wide variety of casting methods, but
the casts used are always below the knee.
One of the disadvantages of casting is
walking with the casts because this is
challenging when retraining a walking
pattern. Also, the number of participants
in the studies was limited (15 or fewer
participants),26-29 and the effectiveness did
not seem to be of long duration.14,30
Botulinum Toxin A (BTX)
BTX has been used in combination with
other treatment modalities such as casting
or physiotherapy.31,32 The effect of BTX
lasts about 2 to 12 months; thereafter, the
children can resume their tiptoe walking
pattern. BTX causes a weakness of the calf
muscles. It results in the achievement of
the heel strike or a near heel strike.7
Three-Step Pyramid Insole
Treatment Concept
The main goal of the pyramid insole
treatment is repositioning the foot bones,
muscles, and ligaments, allowing forefoot
realignment. The pyramid insoles offer
support under the second, third, and
fourth metatarsal bones, having an
impact on the forefoot and the rear foot,
adjusting the gait, and allowing the full
support of the foot (heel and toes) while
walking.
The insole treatment comprises 3
steps3,21,33,34:
Step I: This starts with the use of the
pyramid insole every day for a period
of 6 to 8 weeks; immediately
afterward, a follow-up examination
takes place. In some cases, physical
therapy along with the insoles is
needed (about 15% of the cases).
Step II: During the first examination,
the need for night splints in addition
to the pyramid insoles is determined.
When the range of ankle dorsiflexion
is less than 90°, a night splint is used
in order to increase ankle mobility.
The next follow-up is done after 12 to
14 weeks.
Step III: At the second follow-up after
12 to 14 weeks of therapy with
pyramid insoles and night splints, the
need for BTX is determined. BTX is
used only when the pyramid insoles,
physical therapy, and night splint do
not show enough impact on tiptoe
walking or the ankle joint reaches 90°
of dorsiflexion or less. In this case, 2
applications of BTX on the medial
and lateral head of the gastrocnemius
muscle are done in a period of 12
weeks.
The treatment with this step-by-step
approach with pyramid insoles has
shown a success rate of 70%.3,21,33
Surgery
Surgery is the last option for idiopathic
toe walkers. The aim is to lengthen the
triceps surae muscle tendon complex
when the ankle dorsiflexion angle is
limited or decreased. There are several
surgical procedures such as Achilles
tendon lengthening, the Valpius procedure,
or percutaneous Achilles tendon
Foot & Ankle Specialist 5
lengthening. There is no specific procedure
that will always be recommended. The
number of patients in the studies is
limited,35,36 and these studies do not
compare the surgical outcomes with other
therapeutic approaches. However, surgery
seems to be the best option when there is
an equinus contracture.
Conclusion
Gathering information about this
medical condition will help researchers
and health care practitioners make an
adequate classification and differential
diagnosis of patients with idiopathic toe
walking. However, a lot of information
about toe walking is still missing, and
further investigation is important to
understand its causes, learn more about
the differential diagnosis, and develop
more appropriate treatment
approaches.
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